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493 BC

Hippocrates described patients with "quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression".

Condition attributed to an "overbalance of fire over water”.

Remedy: "barley rather than wheat bread, fish rather than meat, water drinks, and many natural and diverse physical activities."

Circa 1600

Shakespeare referred to a “malady of attention” in one of his characters in King Henry VIII.

Mid 1800s

Heinrich Hoffman, a German physician, penned the poem “Fidgety Phil”.

1890

William James, in his Principles of Psychology text (1890), described a normal variant of character which he called the “Explosive Will”:

“… impulses seem to discharge so promptly onto movements that inhibitions get no time to arise. These are the ‘dare-devil’ and ‘mercurial temperaments, overflowing with animation, and fizzling with talk” (p.800).

Pre-twentieth Century

1902 English physician George Still (1902) reported on a

group of children in his clinical practice whom he defined as having a deficit in “volitional inhibition” or a “defect in moral control” over their behavior.

Their behavior was described as aggressive, passionate, lawless, inattentive, impulsive, and overactive.

An over-representation of male subjects (3:1).

An aggregation of alcoholism, criminal conduct, and depression among the biological relatives.

A familial predisposition to the disorder – hereditary.

Twentieth Century

Minimal Brain Damage/Dysfunction

Interest in children with similar characteristics arose in North America around the time of the encephalitis epidemic of 1917-1918.

Children surviving these brain infections were noted to have many behavioral problems similar to ADHD.

These cases and others known to have arisen from birth trauma, head injury, toxin exposure, and infections gave rise to the concept of a brain-injured child syndrome (Strauus & Lehtinen, 1947).

The brain-injured child syndrome eventually was applied to children manifesting these same behavior features but without evidence of brain damage or retardation.

This concept would later evolve into the concept ‘minimal brain damage’, and eventually ‘minimal brain dysfunction’ (MBD), owing to the dearth of evidence of brain injury in most cases (Dolphin & Cruickshank, 1951; Strauus & Kephardt, 1955).

Minimal Brain Damage/ Dysfunction

Hyperkinetic _____________

During the 1950’s, greater attention was paid to the specific behaviors of hyperactivity and impulsivity resulting in the label “hyperkinetic impulse disorder.” The disorder was attributed to poor thalamic filtering of stimuli entering the brain (Laufer, Denhoff, & Solomons, 1957) and eventually termed the “hyperactive child syndrome” (Chess, 1960).

The influence of psychoanalytic thought at the time held sway when the DSM-II appeared and all childhood disorders were described as “reactions” – the hyperactive child syndrome became “hyperkinetic reaction of childhood” (DSM-II, 1968).

Hyperkinetic Reaction of Childhood

DSM-II (1968)

Characterized by overactivity, restlessness,

distractibility and short attention span, especially

in young children; the behavior usually diminishes

in adolescence. Definition included problems of attention and

distractibility along with those of hyperactivity/

restlessness.

The condition was assumed to be developmentally

benign and not caused by brain damage - resulting in a

departure from European thinking.

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Attention

By the 1970s, research emphasizing the importance of

problems with sustained attention and impulse control in

addition to hyperactivity was emphasized (Douglas, 1972).

Douglas (1980; 1983) theorized that the disorder was

comprised of four major deficits:

The investment, organization, and maintenance of

attention and effort.

The ability to inhibit impulsive behavior.

The ability to modulate arousal levels to meet

situational demands.

An unusually strong inclination to seek immediate

reinforcement.

Douglas’s work coupled with numerous studies of attention,

impulsiveness, and other cognitive sequelae resulted in the

DSM-III (1980) moniker, Attention Deficit Disorder (ADD).

Psychoanalytic perspective discarded.

Cognitive-developmental nature emphasized.

Symptom lists, cutoff scores recommended.

Polythetic categorization scheme (3 major symptom

groupings required for a diagnosis).

Distinction between “with” and “without”

hyperactivity.

Attention-Deficit/Hyperactivity

Disorder (DSM-III-R; 1987)

Hyperactivity and impulsivity Needed to:

Differentiate the disorder from other conditions, and

Predict developmental risks (Weiss & Hechtman, 1993).

Monothetic categorization scheme (14 symptoms - 1

list)

ADD without hyperactivity replaced with

undifferentiated Attention Deficit Disorder

based on insufficient research.

Attention-Deficit/Hyperactivity

Disorder (DSM-IV, 1994)

Three (3) subtypes of ADHD (predominantly inattention; predominantly

hyperactivity-impulsive; and combine type).

Hyperactivity-Impulsive Type appears to be a developmental

precursor to the combined type.

Hyperactive-Impulsive Type was comprised primarily of preschool

children (DSM-IV field trials).

Combined Type and Inattentive Type were comprised primarily of

school-age children.

The Hyperactive-Impulsive behavior pattern seems to emerge first in

development during the preschool years, whereas symptoms of

“inattention” associated with it appear to have their onset several

years later (Loeber et al., 1992; Hart et al., 1995).

Attention-Deficit/Hyperactivity

Disorder (DSM-IV, 1994)

Research began demonstrating that deficits were not limited to the attentional domain. Problems with motivation and insensitivity to response

consequences were emphasized (poor performance under partial reward and extinction - Douglas, 1980s).

Deficient “rule governed” behavior was hypothesized by Barkley (1981; 1989). Information processing paradigms failed to demonstrate that poor performance was due to attentional difficulties vs motivation and response inhibition (Sergeant, 1988). Factor analytic studies failed to differentiate hyperactivity and impulsivity domains (loaded together as 1 factor).

Nomenclature

Attention-Deficit/Hyperactivity Disorder (DSM-III-R, DSM-IV,

DSM-IV-TR)

1987

Attention Deficit Disorder (DSM-III) 1980

Hyperkinetic Reaction of Childhood (DSM-II) 1968

Hyperactive Child Syndrome (Chess) 1960

Hyperkinetic Impulse Disorder (Laufer, Denhoff, & Solomons) 1950s

Minimal Brain Dysfunction (Strauus & Kephardt)

Minimal Brain Damage (Dolphin & Cruikshank) 1940s

Brain Injured Child Syndrome (Strauus & Lehtinen) c. 1918

Volitional Inhibition

Deficit in Moral Control (Still)

1902

Explosive Will (James) 1890

Overbalance of fire over water (Hippocrates) 493 BC

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Evolution of the DSM

Polythetic

Categorization

[multiple lists]

Polythetic

Categorization

[multiple lists]

Monothetic

Categorization

[single list]

Attention-Deficit/Hyperactivity

Disorder (DSM-IV, 1994) continued

Types of problems with “inattention” seen in the Inattentive Type appear to have their onset even later than those associated with hyperactive-impulsive behavior (Barkley, 1996).

Implications: Attentional impairment associated with the Predominantly

Inattentive Type may be different from those seen in the other two types.

Inattentive Type symptoms: daydreaming, spacing out, in a fog, easily confused, staring frequently, lethargic, hypoactive, and passive. [DAMP: developmentally delayed attention, motor and perceptual abilities]

Inattentive Type also appears to have deficits in speed of information processing & focused or selective attention (Goodyear & Hynd, 1992; Lahey & Carlson, 1992).

Combined Type deficits are characterized as consisting of sustained attention (persistence) and distractibility difficulties.

Attention-Deficit/Hyperactivity

Disorder (DSM-IV, 1994) continued

Implications (Continued):

Current clinical view of ADHD may be clustering two

qualitatively different disorders into a single set of

disorder.

Children with ADHD Combined Type who move into

the Inattentive Type (owing to developmental reduction

in hyperactivity) as they get older are not actually

changing types of ADHD; Their attentional problems

should still be distinct (poor persistence, distractibility)

from those seen in the Inattentive Type.

Behavioral Inhibition

Inhibit prepotent response

Stop and ongoing response

Interference control

Motor control/fluency/syntax

Inhibiting task irrelevant responses

Executing goal-directed response

Execution of novel/complex motor sequences

Goal-directed persistence

Sensitivity to response feedback

Task re-engagement following disruption

Control of behavior by internally represented

information

Working Memory

Holding events in mind

Manipulating or acting on events

Initiation of complex behavior

sequences

Retrospective function (hindsight)

Prospective function (forethought)

Anticipatory set

Sense of time

Cross-temporal organization

of behavior

Self-regulation of affect/

motivation/arousal

Emotional self-control

Objectivity/social perspective taking

Self-regulation of drive and motivation

Regulation of arousal in the service of

goal-directed action

Internalization of speechDescription and reflection

Rule-governed behavior

Problem solving/self-questioning

Generation of rules and meta-rules

Moral reasoning

Reconstitution

Analysis and synthesis of behavior

Verbal fluency/behavioral fluency

Goal-directed behavioral creativity

Behavioral simulations

Syntax of behavior

Barkley’s Model

DIAGNOSIS AND ASSESSMENT OF ADHD

CLINICAL INTERVIEWS STRUCTURED INTERVIEWS SEMISTRUCTURED INTERVIEWS

BROAD-BAND RATING SCALES

NARROW-BAND RATING SCALES

NEUROCOGNITIVE ASSESSMENT

CPT PAL

DIFFERENTIAL DIAGNOSIS INTELLIGENCE/ACHIEVEMENT ASSESSMENT

INSTRUMENTS FOR QUALIFYING AND QUANTIFYING CLINICAL SYMTOMATOLOGY IN CHILDREN WITH ADHD

STRUCTURED CLINICAL INTERVIEWS

DIAGNOSTIC INTERVIEW FOR CHILDREN AND ADOLESCENTS [DICA]

DIAGNOSTIC INTERVIEW SCHEDULE FOR CHILDREN [DISC]

SEMI-STRUCTURED CLINICAL INTERVIEWS

CHILDREN’S ASSESSMENT SCHEDULE [CAS] INTERVIEW SCHEDULE FOR CHILDREN [ISC]

KIDDIE-SADS [K-SADS]

BROAD-BAND RATING SCALES AND CHECKLISTS

CHILD BEHAVIOR CHECKLIST [CBCL] CHILD BEHAVIOR CHECKLIST- [CBCL-DOF] CHILD BEHAVIOR CHECKLIST - [CBCL-TRF] CHILD BEHAVIOR CHECKLIST - [YSR] CHILD SYMPTOM INVENTORY [CSI] CONNERS PARENT/TEACHER RATING SCALE - REVISED [CPSQ-R] REVISED BEHAVIOR PROBLEM CHECKLIST [BPC-R] YALE CHILDREN’S INVENTORY [YCI]

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INSTRUMENTS FOR QUALIFYING AND QUANTIFYING CLINICAL SYMTOMATOLOGY

IN CHILDREN WITH ADHD

NARROW-BAND RATING SCALES AND CHECKLISTS ¶ ABBREVIATED CONNERS TEACHER RATING SCALE [ACTRS] · ADD-H COMPREHENSIVE TEACHER RATING SCALE [ACTeRS] ¸ AD/HD RATING SCALE-IV [SCHOOL VERSION] ¹ ACADEMIC PERFORMANCE RATING SCALE [APRS] º HOME SITUATIONS QUESTIONNAIRE - REVISED [HSQ-R] » SCHOOL SITUATIONS QUESTIONNAIRE - REVISED [SSQ-R] ¼ TEACHER SELF-CONTROL RATING SCALE [TSCRS] ½ WERRY-WEISS-PETERS ACTIVITY SCALE [WWPAS]

Rosvold et al. [1956] developed the first CPT for clinical application predicated on EEG evidence suggesting that adults with brain injury should show inferior ability on tasks requiring sustained attention and alertness.

Omission Errors are traditionally thought to

represent one’s ability to remain vigilant over

time.

Commission errors are considered an index of

impulsivity.

CORE FEATURE:

WORKING MEMORY

HYPERACTIVITY

[different functions +

changing topography]

INATTENTION

IMPULSIVITY

Biological

Influences,

e.g., genetics

NEUROBIOLOGICAL

SUBSTRATE

CORE FEATURES:

INATTENTION

HYPERACTIVITY

IMPULSIVITY

SECONDARY

FEATURES/

PROXY VARIABLES

DSM-IV CLINICAL MODEL OF ADHD

ENVIRONMENTAL/

COGNITIVE DEMANDS

WORKING MEMORY